Targeting pain catastrophization in patients with fibromyalgia using virtual reality exposure therapy: a proof-of-concept study

Virtual reality as a treatment for chronic musculoskeletal pain syndromes

Chronic musculoskeletal pain syndromes, including fibromyalgia, are often resistant to conventional medications and invasive therapies. Central hypersensitization, neurotransmitter dysregulation, and autonomic nervous system abnormalities are key pathomechanisms, frequently resulting in widespread pain and a variety of psychosomatic symptoms. Virtual Reality (VR) applications have demonstrated effectiveness in reducing pain, both during and after interventions, and in chronic conditions such as fibromyalgia and back pain. The proposed mechanisms behind VR's effectiveness include distraction and immersion, coupled with cognitive behavioral therapy, which promote neuroplasticity and alter pain perceptions. Functional MRI studies have shown the impact of VR interventions on specific brain regions. Advances in hardware and software, potentially combined with treatments like biofeedback, could enhance VR's role in managing chronic pain. Currently, VR for musculoskeletal pain syndromes is primarily used within multimodal programs, but it is also available for home use as a standalone health application. Future research should focus on the 'drug-like' effects of VR, requiring controlled trials with comparable study populations and appropriate sham interventions.

The effect of virtual reality on pain, kinesiophobia and function in total knee arthroplasty patients: A randomized controlled trial

BACKGROUND

Virtual reality (VR) has emerged as a promising new therapeutic approach, showing promise in the treatment of patients with a variety of diseases. This study aimed to investigate the effect of VR on pain, kinesiophobia, and function in patients undergoing total knee arthroplasty (TKA).

METHODS

This randomized controlled trial was performed on patients who had TKA due to osteoarthritis at Gazi University Hospital from October 2019 to August 2021. For this study, 21 female TKA patients were divided into two groups by the blocked randomization method: VR (n = 10) and exercise (n = 11). The exercise group was given a home exercise program. The VR group received immersive VR application in addition to the exercise. Pain, kinesiophobia, pain catastrophizing, knee range of motion, functional status, and quality of life were assessed. The Wilcoxon Test and Mann-Whitney U Test were used for comparison of the results.

RESULTS

The VR group had a statistically significant difference in the intensity of pain at rest, at night, and during the Timed Up and Go Test (TUG), kinesiophobia, pain catastrophizing, active knee flexion, the TUG, and the stair-climb test scores (P = 0.005 (95% confidence interval (CI) (-5.000, -1.000)), P = 0.005 (95% CI (-7.000, -2.000)), P = 0.023 (95% CI (-4.000, 0)), P = 0.006 (95% CI (-15.000, -3.000)), P = 0.012 (95% CI (-19.000, -3.000)), P = 0.010 (95% CI (4.000, 17.333)), P = 0.017 (95% CI (-14.700, -0.850)), P = 0.011 (95% CI (-23.100, -1.000)), respectively).

CONCLUSION

In the early period following total knee arthroplasty, using virtual reality integrated with exercise helps to reduce pain, kinesiophobia and pain catastrophizing, and to improve functional outcomes in female patients.

Virtual reality to understand pain-associated approach behaviour: a proof-of-concept study

Pain-associated approach and avoidance behaviours are critically involved in the development and maintenance of chronic pain. Empirical research suggests a key role of operant learning mechanisms, and first experimental paradigms were developed for their investigation within a controlled laboratory setting. We introduce a new Virtual Reality paradigm to the study of pain-related behaviour and investigate pain experiences on multiple dimensions. The paradigm evaluates the effects of three-tiered heat-pain stimuli applied contingent versus non-contingent with three types of arm movements in naturalistic virtual sceneries. Behaviour, self-reported pain-related fear, pain expectancy and electrodermal activity were assessed in 42 healthy participants during an acquisition phase (contingent movement-pain association) and a modification phase (no contingent movement-pain association). Pain-associated approach behaviour, as measured by arm movements followed by a severe heat stimulus, quickly decreased in-line with the arm movement-pain contingency. Slower effects were observed in fear of movement-related pain and pain expectancy ratings. During the subsequent modification phase, the removal of the pain contingencies modified all three indices. In both phases, skin conductance responses resemble the pattern observed for approach behaviour, while skin conductance levels equal the pattern observed for the self-ratings. Our findings highlight a fast reduction in approach behaviour in the face of acute pain and inform about accompanying psychological and physiological processes. We discuss strength and limitations of our paradigm for future investigations with the ultimate goal of gaining a comprehensive understanding of the mechanisms involved in chronic pain development, maintenance, and its therapy.

e-Health Interventions Targeting Pain-Related Psychological Variables in Fibromyalgia: A Systematic Review

There is growing evidence to support the potential benefit of e-Health interventions targeting psychosocial outcomes and/or pain-related psychological variables for chronic pain conditions, including fibromyalgia syndrome (FMS). This systematic review aims at providing an in-depth description of the available e-Health psychological and/or multicomponent interventions for patients with FMS. Searches were made in PubMed, Cochrane, Web of Science, and PsycINFO up to 15 May 2023, finally including twenty-six articles. The quality of the included articles was medium-high (average quality assessment score of 77.1%). 50% of studies were randomized controlled trials (RCTs) (n = 13), and the majority of them focused exclusively on adult patients with FMS (n = 23) who were predominantly female. Four categories of e-Health modalities were identified: web-based (n = 19), mobile application (m-Health) (n = 3), virtual reality (VR) (n = 2), and video consulting (n = 2). Interventions were mainly based on the cognitive behavioral therapy (CBT) approach (n = 14) and mostly involved contact with a healthcare professional through different digital tools. Overall, a growing number of psychological and multicomponent interventions have been created and delivered using digital tools in the context of FMS, showing their potentiality for improving psychosocial outcomes and pain-related psychological variables. However, some digital tools resulted as underrepresented, and the literature on this topic appears highly heterogeneous precluding robust conclusions.

Benefits of Exergame Training for Female Patients With Fibromyalgia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

OBJECTIVE

The objective of this systematic review and meta-analysis was to evaluate the effects of exergame training on female patients with fibromyalgia syndrome (FMS). Outcome measurements mainly include overall functioning, pain perception, quality of life, exercise capacity, health perception, kinesiophobia, and fatigue severity.

DATA SOURCES

Five electronic databases (PubMed, Web of Science, PsycInfo, Scopus, and Cochrane Library) were searched from inception until June 24, 2021. In addition to searches, review the reference lists of relevant papers by hand was also conducted. Cochrane Collaboration's tool for assessing risk of bias was used to evaluate the risk of bias in the included studies.

STUDY SELECTION

Articles were collected with the following study inclusion criteria: (1) randomized controlled trial (RCT) design; (2) participants were female patients with FMS aged older than 18 years; (3) participants in experimental groups received exergame training using any modality; and (4) outcome measures included overall functioning, quality of life, exercise capacity, health perception, kinesiophobia, and fatigue severity.

DATA EXTRACTION

The data were independently extracted by 2 researchers. The extracted data related to the document characteristics (first author, publication year, and country) participant characteristics (number and age of participants in the experimental and control groups), and interventions (intervention content, frequency, and duration, and measurement tools).

DATA SYNTHESIS

Nine RCTs including 466 female patients with FMS were included in the analysis. Exergame training had significant positive effects on overall functioning (standardized mean difference [SMD], -0.52; 95% confidence interval [CI], -0.77 to 0.27; P<.0001), pain perception (SMD, -0.49; 95% CI, -0.97 to -0.02; P=.04), quality of life (SMD, 0.77; 95% CI, 0.44-1.10; P<.00001), exercise capacity (SMD, 0.58; 95% CI, 0.32-0.84; P<.0001), health perception (SMD, 0.69; 95% CI, 0.38-1.01; P<.0001), and fatigue severity (SMD, -0.97; 95% CI, -1.55 to -0.38; P=.001). However, exergame training did not have significant effects on kinesiophobia (SMD, -1.13; 95% CI, -2.88 to 0.62; P=.21).

CONCLUSIONS

Exergame training has beneficial effects on the overall functioning, pain perception, quality of life, exercise capacity, health perception and fatigue severity of female patients with FMS. Exergame training is a potential non-drug therapy for the treatment of patients with FMS.

Immersive virtual reality to relieve exercise-induced pain caused by aerobic cycling

Chronic pain affects 20% of the global population and is incredibly complex to treat. The burden of chronic pain is physical, emotional and financial, and prevalence rates continue to rise. Current treatments are ineffective long-term against pain and common comorbidities, including anxiety and depression, mood and sleep disorders, and social isolation. While a large body of evidence supports regular physical exercise as an effective long-term treatment for chronic pain and its comorbidities, exercise-induced pain and kinesiophobia are significant barriers to participation and adherence. Immersive virtual reality is a powerful short-term pain reliever, that, when combined with exercise, can help overcome these barriers. This perspective argues for the use of combined exercise and virtual reality treatment techniques to mitigate chronic pain.

The Analgesic Effects of Virtual Reality for People with Chronic Pain: A Scoping Review

OBJECTIVE

Although virtual reality is shown to have short-term analgesic effects in acute pain settings, its long-term efficacy in chronic pain conditions has not been established. This scoping review aims to provide a summary of virtual reality approaches explored in chronic primary and secondary pain conditions as defined by the International Association for the Study of Pain.

METHODS

A systematic literature search in Ovid PubMed and Ovid Embase was conducted between January 5 and January 10, 2021, with the use of the Arksey and O'Malley six-step scoping review criteria. Articles were searched via search terms and keywords relating to International Classification of Diseases-defined primary and secondary chronic pain conditions, virtual reality, virtual illusion, distraction, and effects on levels of pain.

RESULTS

Of the 2,118 articles located, 44 were included, which covered a range of primary and secondary chronic pain conditions and used a variety of different computer screen and headset protocols, including gaming, mindfulness, exercise, relaxation, and proprioceptive skills.

CONCLUSIONS

Studies show virtual reality to be an effective analgesic intervention for people with chronic pain. Given user satisfaction, a lack of side effects such as cybersickness, and relief of comorbid symptoms, virtual reality has potential as a worthwhile adjunct to chronic pain management programs, thus enabling patients to take control of their symptoms.

The use of virtual reality in non-burn dermatological care - a review of the literature

Aim: Virtual Reality (VR) is the artificial depiction of a three-dimensional (3D) environment using computer-generated technology which allows users to interact with a simulated setting. VR has been used in a variety of clinical scenarios due to its efficacy as a distraction intervention, reducing anxiety and pain associated with medical procedures. The aim of this review is to provide clinicians with an overview of VR use in clinical dermatology.Methods: A search on VR use in clinical dermatology was conducted using PubMed Medline, Embase, Cochrane, Google Scholar and ClinicalTrials.Gov in July 2019. Results related to burn care were excluded.Results: This review identifies studies that utilized VR in the management of skin diseases and discusses considerations for its future use.Conclusion: The findings of these studies indicate that VR has beneficial effects as a complementary tool in the treatment of dermatological conditions.

Symptom reduction and improved function in chronic CRPS type 1 after 12-week integrated, interdisciplinary therapy

Background and aims Complex Regional Pain Syndrome (CRPS) often recovers spontaneously within the first year, but when it becomes chronic, available rehabilitative therapies (pharmacological management, physiotherapy, and psychological intervention) have limited effectiveness. This study examined the effect of a 12-week intensive outpatient rehabilitation on pain relief and function in chronic CRPS patients. Rehabilitation program included memantine and morphine treatment (added to patient's prior pain medication) and concurrent psychological and physiotherapeutic intervention. Primary outcome measure was a change in CRPS symptom count and secondary outcomes were motor performance, psychological factors, pain intensity, and quality of life. Methods Ten patients with chronic upper limb CRPS I (median 2.9 years, range 8 months to 12 years) were recruited to the study and were assessed before and after the intervention. Hand motor function of the patients was evaluated by an independent physiotherapist. There were standardized questionnaires for depression, pain anxiety, pain acceptance, quality of life, and CRPS symptom count. In addition, psychological factors were evaluated by a semi-structured interview. Severity of experienced pain was rated at movement and at rest. In addition, a video experiment of a hand action observation was conducted pre- and post-intervention to study possible change in neuronal maladaptation. Intervention consisted of pharmacological, psychological and physiotherapeutic treatment. First, 10 mg daily morphine was started and increased gradually to 30 mg daily, if tolerated. After 30 mg/day or tolerated dose of morphine was achieved, 5 mg daily memantine was started and increased gradually to 40 mg, if tolerated. Psychological intervention consisted of weekly group sessions, using cognitive and behavioral methods (relaxation, behavioral activation, and exposure) and acceptance and commitment therapy (ACT) and daily home practice. Physiotherapeutic intervention consisted of graded motor imagery and physiotherapy exercises with weekly group sessions and/or individual guidance by the physiotherapist, and individual exercise of the affected upper limb. Results Multimodal intensive intervention resulted in significant decrease in CRPS symptom count. The effect was strongest in motor and trophic symptoms (19% decrease after intervention) and in sensory symptoms (18% decrease). Additionally, improvement was seen in some, but not all, secondary outcomes (movement pain, motor symptoms, change in perceptions during video experiment of hand actions, and summary index with motor functioning, pain, and psychological factors). There were no dropouts. Conclusions Intensive 12-week multimodal intervention reduced some CRPS symptoms but was not sufficient to alter patients' rest pain, distress, or quality of life. Implications These results support the efficacy of an interdisciplinary rehabilitation program for pain and function in chronic CRPS patients. After intervention, some CRPS symptoms reduced and function improved, but distress and quality of life were unchanged. This may be due to the relatively short duration of this program; to delayed effects; to particular cognitive problems of CPRS patients; and/or to low distress levels at baseline that make statistically significant reduction less likely.

Digital Medicine in Rheumatology: Challenges and Opportunities

The exponential growth in technology has had a significant effect on the practice of medicine and will likely transform the practice of medicine. In this article, the authors review select technologies that are already influencing the practice of rheumatology. Social media Websites such as Twitter are now important sources of information and discussion for health care professionals interested in rheumatology. Virtual reality is an innovative technology with great potential for acute and chronic pain management. The authors also review several low-cost technology alternatives to commonly used tools used in rheumatology.

A systematic review of structural and functional MRI studies on pain catastrophizing

Objectives: Pain catastrophizing is reliably associated with pain reports during experimental pain in healthy, pain-free subjects and in people with chronic pain. It also correlates with self-reports of clinical pain intensity/severity in a variety of disorders characterized by chronic pain in adults, adolescents and children. However, processes, through which it exerts its effects are yet unclear. In this paper, our primary aim was to synthesize neuroimaging research to open a window to possible mechanisms underlying pain catastrophizing in both chronic pain patients and healthy controls. We also aimed to compare whether the neural correlates of pain catastrophizing are similar in these two groups.

Methods: PubMed and the Web of Science were searched for magnetic resonance imaging (MRI) studies that explored neural correlates of pain catastrophizing.

Results: Twenty articles met the inclusion criteria. The results of our review show a connection between pain catastrophizing and brain areas tightly connected to pain perception (including the somatosensory cortices, anterior insula, anterior cingulate cortex and thalamus) and/or modulation (eg, the dorsolateral prefrontal cortex). Our results also highlight that these processes - in relation to pain catastrophizing - are more pronounced in chronic pain patients, suggesting that structural and functional brain alterations (and perhaps mechanisms) related to pain catastrophizing may depend on prior and/or relatively stable/constant pain experience. However, we also found methodological issues and differences that could lead to divergent results.

Discussion: Based on our results, pain catastrophizing might be related to salience detection, pain processing, and top-down attentional processes. More research is recommended to explore neural changes to specific types of catastrophizing thoughts (eg, experimentally induced and/or state). Furthermore, we provide ideas regarding pain catastrophizing studies in the future for a more standardized approach.

Group Cognitive Behavior Therapy Reversed Insula Subregions Functional Connectivity in Asthmatic Patients

Background: Group cognitive behavior therapy (GCBT) is an effective treatment in improving self-management behaviors and quality of life for asthmatic patients. However, the mechanisms by which GCBT improves asthma-related clinical symptoms remain unknown. Previous studies have indicated that insula is an important region involved in the neuropathology of asthma. Therefore, we examined the possible alteration of functional connectivity (FC) in insula subregions after GCBT in asthmatic patients. Methods: Forty-two asthmatic patients and 60 healthy controls (HCs) received resting-state functional magnetic resonance imaging (rs-fMRI) scan and clinical assessments, 17 asthmatic patients completed GCBT treatment consisting of 8 sessions, and then received rs-fMRI scan and clinical assessments. Results: Asthmatic patients had greater left ventral anterior insula (vAI) FC with the left cerebellum posterior lobe, right middle temporal gyrus, and bilateral anterior cingulate cortex (ACC), but less FC with bilateral postcentral gyrus, bilateral occipital lobe, and left precentral gyrus compared with HCs. FC between left posterior insula and left medial frontal gyrus also increased in the patients. In addition, right vAI showed increased FC with right caudate and left putamen. FC between right dorsal anterior insula (dAI) and left calcarine however decreased. The increase in FC in insula subregions were significantly improved following GCBT. FC between the left vAI connectivity and left postcentral gyrus was positively correlated with the percentage of improvement in 17-items Hamilton depression rating scale scores, and FC between the right dAI and left calcarine was negatively associated with the improvement percentage in asthma control test scores. Conclusions: This study in the first time demonstrated that GCBT led to significant improvement of FC between insula subregions and other brain regions. Clinical Trial Registration: An investigation of therapeutic mechanism in asthmatic patients: based on the results of Group Cognitive Behavioral Therapy (Registration number: ChiCTR-COC-15007442) (http://www.chictr.org.cn/usercenter.aspx).